CCE-CBD-076

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. Take a focused history to clarify the mechanism of injury and assess infection risk

• Prompt: How did the injury occur?
• Prompt: What is the wound contamination level?
• Prompt: Tetanus immunisation history?
• Prompt: Ask about any systemic symptoms.

Q2. Perform a focused examination and describe your findings

• Prompt: Describe wound characteristics (size, depth, contamination).
• Prompt: Assess for neurovascular compromise.
• Prompt: Check for signs of infection or foreign bodies.
• Prompt: Assess tetanus risk based on wound status.

Q3. Develop an immediate management plan for wound care

• Prompt: Explain wound cleaning and debridement.
• Prompt: Discuss closure methods (e.g., delayed primary closure).
• Prompt: Decide on antibiotic prophylaxis.
• Prompt: Tetanus immunisation update.

Q4. Discuss preventive health advice relevant to this case

• Prompt: Smoking cessation and wound healing.
• Prompt: Weight management.
• Prompt: Workplace safety practices.
• Prompt: Vaccination catch-up.

Q5. Explain signs of wound complications and when to seek further help

• Prompt: Signs of infection to watch for (redness, warmth, pus, fever).
• Prompt: Advise return for review if signs develop.
• Prompt: Discuss timing for suture removal if applicable.
• Prompt: Discuss potential need for escalation if systemic signs appear.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: Take a focused history to clarify the mechanism of injury and assess infection risk

The competent candidate should:

• Confirm the exact mechanism of injury, clarifying how and when it happened (e.g., falling on-site, hitting a rusty metal object).
• Explore the wound contamination level—presence of soil, debris, rust, and any attempts at initial cleaning.
• Determine tetanus immunisation history—when (if ever) the patient last had a tetanus booster.
• Explore red flags for systemic illness or signs of infection (e.g., fever, chills, lymphangitis).
• Ascertain allergy history, particularly to antibiotics or vaccines.
• Clarify comorbidities (e.g., diabetes, peripheral vascular disease) that may impair wound healing.
• Explore patient’s concerns (infection, work absence, scarring).

Q2: Perform a focused examination and describe your findings

The competent candidate should:

• Inspect and describe the wound: size (4 cm), location (anterior tibia), depth (superficial), and contamination (soil/rust debris).
• Evaluate wound edges for approximation and surrounding erythema, warmth, or signs of infection.
• Check neurovascular status of the limb—capillary refill, pulses, sensation, and movement.
• Look for foreign bodies within the wound.
• Assess systemic signs, such as temperature, general appearance, and vital signs, to rule out systemic infection.
• Identify risks of tetanus based on wound nature and immunisation status.

Q3: Develop an immediate management plan for wound care

The competent candidate should:

• Explain the need for wound cleaning and irrigation with sterile saline to remove contaminants.
• Perform debridement of devitalised tissue if necessary.
• Recommend delayed primary closure, considering contamination—close the wound after 48-72 hours if no infection develops.
• Prescribe antibiotics: empiric coverage for skin flora and environmental contaminants (e.g., flucloxacillin or cephalexin); consider broader coverage if severe contamination.
• Provide tetanus prophylaxis: administer tetanus toxoid booster and tetanus immunoglobulin if high-risk wound and immunisation uncertain.
• Apply an appropriate dressing and advise on wound care at home.
• Plan for review within 48 hours to assess for infection before considering closure.

Q4: Discuss preventive health advice relevant to this case

The competent candidate should:

• Advise on smoking cessation to promote wound healing (offer Quitline referral or pharmacotherapy).
• Discuss weight management to reduce future injury risks and improve healing.
• Encourage safe work practices and appropriate use of PPE on-site.
• Offer vaccination catch-up, including tetanus, influenza, and COVID-19.
• Reinforce the importance of wound care hygiene and early presentation if complications arise.

Q5: Explain signs of wound complications and when to seek further help

The competent candidate should:

• Educate on signs of infection: increased redness, warmth, swelling, pus discharge, pain, or systemic signs (fever, malaise).
• Advise on wound review in 48 hours, or sooner if concerning signs develop.
• Explain need for urgent review if symptoms of sepsis arise (fever, tachycardia, hypotension).
• Discuss delayed closure plan and removal of any sutures (if placed) within 7-10 days.
• Provide written instructions for wound care and emergency contact details.

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SUMMARY OF A COMPETENT ANSWER

• Clarifies injury mechanism and assesses for infection and tetanus risk.
• Performs thorough examination, including neurovascular assessment and wound description.
• Develops appropriate wound management plan, including cleaning, debridement, delayed closure, antibiotics, and tetanus prophylaxis.
• Provides preventive health advice: smoking cessation, vaccination, and workplace safety.
• Educates patient on wound complications and follow-up needs.

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PITFALLS

• Failing to assess tetanus immunisation status and provide appropriate prophylaxis.
• Overlooking neurovascular assessment of the affected limb.
• Closing the wound too early despite contamination, increasing infection risk.
• Not prescribing appropriate antibiotics when indicated.
• Inadequate patient education on wound care and signs of infection.
• Ignoring preventive health opportunities like smoking cessation and vaccination.

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REFERENCES

• RACGP Red Book (9th Edition)
• Therapeutic Guidelines on Antibiotic (Version 17)
• Australian Immunisation Handbook
• Murtagh’s General Practice, 8th Edition

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives.

2. Clinical Information Gathering and Interpretation

2.1 Elicits an appropriate history informed by the patient’s context.
2.2 Performs a relevant physical examination and assessment, identifies abnormal findings.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates hypotheses and establishes a provisional diagnosis.
3.2 Demonstrates diagnostic reasoning with consideration of differentials.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a management plan with appropriate treatments and referrals.
4.2 Explains therapeutic options and engages in shared decision making.

5. Preventive and Population Health

5.1 Provides advice on wound care and tetanus immunisation.

6. Professionalism

6.1 Provides respectful care, ensuring patient understanding of treatment options and risks.

7. General Practice Systems and Regulatory Requirements

7.1 Documents care and manages clinical risk (e.g., wound infection monitoring).

8. Procedural Skills

8.1 Performs minor skin procedures, including wound closure and dressing.

9. Managing Uncertainty

9.1 Recognises and manages clinical uncertainty (e.g., infection risk, foreign body presence).

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies signs of systemic infection requiring escalation.

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Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD